Alcohol

Alcohol use can cause numerous adverse effects on the fetus, the most severe outcomes
being mortality and fetal alcohol syndrome (FAS)). However, the specific amount of
alcohol exposure required to cause FAS has not been determined. Dose, timing, duration
of exposure, genetic factors, and protective factors are all contributors). Studies suggest
that approximately nine to ten of every 1,000 live births are negatively affected by
alcohol consumption during pregnancy.
According the IOM, the diagnosis of FAS requires
(a) confirmed maternal exposure,
(b) the presence of a characteristic pattern of facial anomalies,
(c) growth retardation,
(d) and central nervous system neurodevelopmental abnormalities

The characteristic facial features include short palpebral fissures, epicanthal folds,
midface hypoplasia, depressed wide nasal bridge, anteverted nares, long hypoplastic
philtrum, and a thin upper vermilion border
Central nervous system abnormalities can include decreased head size, brain structure
abnormalities, impaired fine motor skills, hearing loss, poor tandem gait, and poor hand-
eye coordination.
Growth retardation typically continues after delivery and often persists into adolescence

The only preventive measure for FAS and milder versions of the disorder known as
partial FAS is the complete abstinence from alcohol during pregnancy. Longitudinal data
suggest that deficits in height, weight, head circumference, palpebral fissues, and skinfold
thickness are apparent even among light drinkers consuming up to 1.5 drinks/ week (62).

Smoking
Cigarette smoking during pregnancy is linked to preterm delivery, spontaneous
abortion, and LBW. Carbon monoxide and nicotine from cigarettes increase fetal
carboxyhemoglobin and reduce placental blood flow, thus limiting oxygen delivery
to the fetus. Even light smoking (fewer than five cigarettes/day) is associated with

Illicit Drugs
In addition to alcohol and tobacco, illicit drugs such as marijuana, cocaine, and heroin
can have devastating effects on a developing fetus. Although it is often difficult to isolate
the effects of an illicit drug from concurrent use of alcohol and/or tobacco, marijuana and
cocaine have been linked to reduced fetal growth . Cocaine use has also been associated
with premature labor and spontaneous abortion. Exposure to heroin and other opiates
leads to a withdrawal syndrome that affects the central nervous, autonomic, and
gastrointestinal systems . Although most outcomes of prenatal illicit drug use are
limited to the early postnatal period, results are emerging from longitudinal studies that
suggest longer-term effects on language function (67) and academic achievement (68).
Caffeine
The need to restrict or eliminate caffeine intake during pregnancy remains controversial.
Caffeine is metabolized more slowly in pregnant woman and passes readily through
the placenta to the fetus. High caffeine intake has been shown to be teratogenic in
animal studies and has been linked to LBW in humans, although some studies suggest
that this association occurs most often in combination with smoking. Given that most
caffeine-containing foods are low in nutritional value (e.g., coffee, tea, colas, and other
soft drinks), it is prudent for pregnant women to limit their caffeine consumption.

Herbal and Other Dietary Supplements

Although many pregnant women benefit from supplementation with vitamins and/or
minerals to achieve the recommended nutrient intakes in pregnancy, less is known about
benefits or risks of herbal and other dietary supplements. Very few studies have
examined the efficacy and safety of alternative therapies during pregnancy (70), and so it
is most prudent to consider these remedies as suspect until proven safe. Remedies
promoted to pregnant women are often for easing gastrointestinal distress (71). Although
ginger shows promise for relieving the nausea and vomiting of early pregnancy (72),
other botanical therapies such as red raspberry, peppermint, and wild yam have not been
formally studied.

Many herbal products have been identified as potentially unsafe for use during pregnancy
(1). Safety issues range from potential embryotoxicity to the more likely hormonal effects
and drug interactions (73). Given the lack of premarket requirements for proof of safety
and efficacy for dietary supplements, pregnant women should discuss such supplements
with their health care provider before continuing to use them. Unfortunately, sometimes
advice of the health care provider carries its own risks. Finkel and Zarlengo reported a
case of a woman advised by her obstetrician to drink a tea made from blue cohosh, an
herb used in Native American medicine to induce labor (74). Two days after delivery, the
infant suffered a stroke, and the cocaine metabolite benzoylecgonine was detected in the
infant's urine and in the mother's bottle of blue cohosh. It was not known whether
benzoylecgonine is also a metabolite of blue cohosh or whether the supplement was
contaminated with cocaine or if toxicologic testing may have identified a cross-reacting
substance. Other reports of contaminants found in supplements have surfaced, including a
finding of the alkaloid colchicine in placental blood of patients using a commercially
available ginkgo biloba product (75).